Showing papers in "Postgraduate Medicine in 2019"
TL;DR: Although less data is published about anxiety and pain, the relationship is consistent across studies as increased anxiety leads to increased severity of pain perceived and decreased pain tolerance.
Abstract: Pain is a subjective experience that is influenced by genetics, gender, social, cultural and personal parameters. Opposed to chronic pain, which by definition has to last for at least 3 months, acu...
156 citations
TL;DR: Evidence supports the redefinition of chronic pain as a distinct disease entity, not simply a symptom of injury or illness, and clinicians need to adopt a practical integrated management approach.
Abstract: Chronic pain is a common public health problem that has a detrimental impact on patient health, quality of life (QoL), and function, and poses a substantial socioeconomic burden. Evidence supports the redefinition of chronic pain as a distinct disease entity, not simply a symptom of injury or illness. Chronic pain conditions are characterized by three types of pain pathophysiology (i.e. nociceptive, neuropathic, and centralized pain/central sensitization) influenced by a cluster of coexisting psychosocial factors. Negative risk/vulnerability factors (e.g. mood or sleep disturbances) and positive resilience/protective factors (e.g. social/interpersonal relationships and active coping) interact with pain neurobiology to determine patients' unique pain experience. Viewing chronic pain through a biopsychosocial lens, instead of a purely biomedical one, clinicians need to adopt a practical integrated management approach. Thorough assessment focuses on the whole patient (not just the pain), including comorbidities, cognitive/emotional/behavioral characteristics, social environment, and QoL/functional impairment. As for other complex chronic illnesses, the treatment plan for chronic pain can be developed based on pain subtype and psychosocial profile, incorporating pharmacotherapy and self-management modalities. Preferred pharmacologic treatment of conditions primarily associated with nociception (e.g. osteoarthritis) includes acetaminophen and non-steroidal anti-inflammatory drugs, whereas preferred pharmacologic treatment of conditions primarily associated with neuropathy or central sensitization (e.g. fibromyalgia) includes tricyclic compounds, serotonin-norepinephrine reuptake inhibitors, and α2δ ligands. Education, exercise, cognitive behavioral therapy, and many other non-pharmacological approaches, alone or combined with pharmacotherapy, have been shown to be effective for any type of pain, although they remain underutilized due to lack of awareness of their benefits and reimbursement obstacles.
106 citations
TL;DR: increasing the EPA:AA ratio through treatment with purified EPA has been shown in clinical studies to be effective in primary and secondary prevention of coronary artery disease and reduces the risk of cardiovascular events following percutaneous coronary intervention.
Abstract: Eicosapentaenoic acid (EPA) is a key anti-inflammatory/anti-aggregatory long-chain polyunsaturated omega-3 fatty acid. Conversely, the omega-6 fatty acid, arachidonic acid (AA) is a precursor to a number of pro-inflammatory/pro-aggregatory mediators. EPA acts competitively with AA for the key cyclooxygenase and lipoxygenase enzymes to form less inflammatory products. As a result, the EPA:AA ratio may be a marker of chronic inflammation, with a lower ratio corresponding to higher levels of inflammation. It is now well established that inflammation plays an important role in cardiovascular disease. This review examines the role of the EPA:AA ratio as a marker of cardiovascular disease and the relationship between changes in the ratio (mediated by EPA intake) and changes in cardiovascular risk. Epidemiological studies have shown that a lower EPA:AA ratio is associated with an increased risk of coronary artery disease, acute coronary syndrome, myocardial infarction, stroke, chronic heart failure, peripheral artery disease, and vascular disease. Increasing the EPA:AA ratio through treatment with purified EPA has been shown in clinical studies to be effective in primary and secondary prevention of coronary artery disease and reduces the risk of cardiovascular events following percutaneous coronary intervention. The EPA:AA ratio is a valuable predictor of cardiovascular risk. Results from ongoing clinical trials will help to define thresholds for EPA treatment associated with better clinical outcomes.
84 citations
TL;DR: Many mechanisms have been suggested (and possibly act cumulatively) for the cardioprotective effects of SGLT2 inhibitors.
Abstract: Sodium-glucose co-transporter 2 (SGLT2) inhibitors inhibit glucose re-absorption in the proximal renal tubules. Two trials have shown significant reductions of cardiovascular (CV) events with empagliflozin and canagliflozin, which could not be attributed solely to their antidiabetic effects. The aim of the review is the critical presentation of suggested mechanisms/hypotheses for the SGLT2 inhibitors' cardioprotection. The search of the literature revealed many possible cardioprotective mechanisms, because SGLT2 inhibitors (i) increase natriuresis and act as diuretics with unique properties leading to a reduction in preload and myocardial stretch (the diuretic hypothesis); (ii) decrease blood pressure and afterload (the blood pressure lowering hypothesis), (iii) favor the production of ketones, which can act as a 'superfuel' in the cardiac and renal tissue (the 'thrifty substrate' hypothesis), (iv) improve many metabolic variables (the metabolic effects hypothesis), (v) exert many anti-inflammatory effects (the anti-inflammatory effects hypothesis), (vi) can act through the angiotensin II type II receptors in the context of simultaneous renin-angiotensin-aldosterone-system (RAAS) blockade leading to vasodilation and positive inotropic effects (the RAAS hypothesis), (vii) directly decrease the activity of the upregulated in heart failure Na+-H+ exchanger in myocardial cells leading to restoration of mitochondrial calcium handling in cardiomyocytes (the sodium hypothesis). Additionally, some SGLT2 inhibitors exhibit also SGLT1 inhibitory action possibly resulting in an attenuation of oxidative stress in ischemic myocardium (the SGLT1 inhibition hypothesis). Thus, many mechanisms have been suggested (and possibly act cumulatively) for the cardioprotective effects of SGLT2 inhibitors.
66 citations
TL;DR: Renal benefits among patients with CKD are similar to those without CKD and include a significant reduction in albuminuria and reduced incidence of worseningalbuminuria, and these agents should be considered as preferred add-on agents in most patients with uncontrolled T2DM and eGFR >30 ml/min/1.73 m2.
Abstract: Objective: To review glucose-lowering efficacy and changes in renal function associated with sodium-glucose co-transporter 2 (SGLT2) inhibitors among patients with chronic kidney disease (C...
61 citations
TL;DR: The blood pressure-lowering effect of SGLT2 inhibitors is maintained in people with CKD and could further contribute to reduced renal burden, as well as potentially offering synergistic effects with antihypertensive therapies in these patients.
Abstract: Chronic kidney disease (CKD) is a frequent complication of type 2 diabetes mellitus (T2DM) and is associated with poor clinical outcomes, including an increased risk of all-cause and cardiovascular mortality, as well as adverse economic and social effects. Slowing the development and progression of CKD remains an unmet clinical need in patients with T2DM. Sodium-glucose co-transporter 2 (SGLT2) inhibitors are widely used for the management of T2DM and have effects beyond glucose lowering that include cardiovascular benefits and potential renoprotective effects. Although the glucose-lowering efficacy of these agents is dependent on renal function, the cardiovascular and renal benefits of SGLT2 inhibition appear to be maintained to estimated glomerular filtration levels as low as 30 mL/min/1.73 m2. Clinical evidence has indicated that these agents can reduce the risk of development or worsening of albuminuria, a marker of renal damage, through a range of mechanisms. These include blood pressure lowering, reduction of intraglomerular pressure and hyperfiltration, modification of inflammatory processes, reduction of ischemia-related renal injury, and increases in glucagon levels. The blood pressure-lowering effect of SGLT2 inhibitors is maintained in people with CKD and could further contribute to reduced renal burden, as well as potentially offering synergistic effects with antihypertensive therapies in these patients. Several cardiovascular outcomes trials (CVOTs) have included renal endpoints, adding to the growing evidence of the potential renoprotective effects of these agents in patients with T2DM. Several ongoing dedicated renal outcomes trials will provide further guidance on the potential clinical role of SGLT2 inhibitors in slowing the development and progression of renal impairment in individuals with T2DM.
54 citations
TL;DR: The issues faced by older people with T2D, the risk factors for hypoglycemia in this population, and the challenges faced by health care providers regarding glycemic management in this patient group are highlighted.
Abstract: Treatment of older adults with type 2 diabetes (T2D) is complex because they represent a heterogeneous group with a broad range of comorbidities, functional abilities, socioeconomic status, and life expectancy. Older adults with T2D are at high risk of recurring hypoglycemia, a condition associated with marked morbidity and mortality, because their counter-regulatory mechanism to hypoglycemia is attenuated, and recurring hypoglycemic episodes can lead to hypoglycemia unawareness. In addition, polypharmacy, a result of multiple chronic comorbidities (including heart disease, stroke, and chronic kidney disease), can increase the risk of severe hypoglycemia, especially when patients are taking sulfonylureas or insulin. Often the signs of hypoglycemia are nonspecific (sweating, dizziness, confusion, visual disturbances) and are mistaken for neurological symptoms or dementia. Consequences of hypoglycemia include acute and long-term cognitive changes, cardiac arrhythmia and myocardial infarction, serious falls, frailty, and death, often resulting in hospitalization, which come at a high economic cost. The American Diabetes Association has recently added three new recommendations regarding hypoglycemia in the elderly, highlighting individualized pharmacotherapy with glucose-lowering agents with a low risk of hypoglycemia and proven cardiovascular safety, avoidance of overtreatment, and simplifying treatment regimens while maintaining HbA1c targets. Thus, glycemic goals can be relaxed in the older population as part of individualized care, and physicians must make treatment decisions that best serve their patients' circumstances. This article highlights the issues faced by older people with T2D, the risk factors for hypoglycemia in this population, and the challenges faced by health care providers regarding glycemic management in this patient group.
50 citations
TL;DR: Evaluating epidemiology, clinical manifestations, and survival of patients with PLC reported in the literature from 1970 to 2018 observed better results achieved in patients described between 2000 and 2018 compared to 1970 through 1999.
Abstract: Pulmonary lymphangitis carcinomatosis (PLC) is a life-threating complication in patients suffering from malignancies. Misleading and nonspecific symptoms often result in a delayed diagnosis. This r...
43 citations
TL;DR: The analysis of data suggests that the existence of the obesity paradox is questionable based on the single use of BMI as a measure of obesity, and the use of waist circumference and waist to hip ratio are better indices of obesity and should be used together with the BM.
Abstract: Overweight and obesity in children and adults have significantly risen in the US and worldwide due to biological, environmental, and cultural drivers and account for about 2.1 billion people. In addition, obesity, even metabolically healthy, is a major risk factor for the metabolic syndrome, diabetes mellitus, dyslipidemia, and hypertension, all significant causes of cardiovascular disease (CVD), coronary heart disease (CHD) heart failure (HF) and stroke. However, despite these causative effects, overweight and obesity frequently, confer protection in patients with established CVD, CHD, HF, and hypertension, compared to normal weight persons, the so-called 'obesity paradox'. This phenomenon though is not unique, because other studies have not shown a protective effect of overweight and obesity in such patients. These controversial effects of obesity are mostly due to the use of different indices of obesity by the various studies. Most studies have used the body mass index (BMI) as an index of obesity, which is a poor index for total fat or fat distribution. In order to get a better perspective on the true nature of the obesity paradox, a Medline and Embase search of the English language literature was contacted from 2012 to 2018, using the terms, overweight, obesity, obesity paradox, CVD, HF, and hypertension. From this search, 37 pertinent papers were selected and their findings together with collateral literature will be discussed in this review. The analysis of data suggests that the existence of the obesity paradox is questionable based on the single use of BMI as a measure of obesity. The use of waist circumference and waist to hip ratio are better indices of obesity and should be used together with the BM.
36 citations
TL;DR: Current evidence supports hypertension, hypotension, heart failure, stroke and coronary artery diseases as potential factors playing a role in cognitive decline in patients with Alzheimer’s dementia.
Abstract: Alzheimer's disease (AD) is the most common form of dementia manifesting as alterations in cognitive abilities, behavior, and deterioration in memory which is progressive, leading to gradual worsening of symptoms. Major pathological features of AD are accumulations of neuronal amyloid plaques and neurofibrillary tangles, with early lesions appearing primarily in the hippocampus, the area of the brain involved in memory and learning. Cardiovascular-related risk factors are believed to play a crucial role in disease development and the acceleration of cognitive deterioration by worsening cerebral perfusion, promoting disturbances in amyloid clearance. Current evidence supports hypertension, hypotension, heart failure, stroke and coronary artery diseases as potential factors playing a role in cognitive decline in patients with Alzheimer's dementia. Although dementia due to cardiovascular deficits is more strongly linked to the development of vascular dementia, a stepwise decline in cognition, recent researches have also discovered its deleterious influence on AD development.
34 citations
TL;DR: The improved return to work outcomes and opiate reductions suggest that cost-effectiveness as well as clinical effectiveness may be achieved with this treatment approach.
Abstract: Objective: To report on the long-term outcomes for patients receiving paraesthesia-free high-frequency spinal cord stimulation (HF10-SCS) at 10 kHz for the treatment of combined upper and lower bod...
TL;DR: Diagnosis of BV has traditionally depended on the presence of vaginal discharge and odor, elevated pH, and clue cells as determined by microscopy, but newer diagnostic modalities that utilize molecular techniques allow for more convenient and accurate testing for BV.
Abstract: Bacterial vaginosis (BV) affects approximately one third of women in the United States. While often asymptomatic, BV infection may be accompanied by serious health consequences, such as preterm birth and pelvic inflammatory disease, and may facilitate acquisition of sexually transmitted infections. Identifying appropriate patients for screening, such as pregnant women, women planning pregnancy, and women with multiple and/or new sexual partners, is imperative for treatment. Diagnosis of BV has traditionally depended on the presence of vaginal discharge and odor, elevated pH, and clue cells as determined by microscopy, but newer diagnostic modalities that utilize molecular techniques allow for more convenient and accurate testing for BV. Approved treatment options consist of antibiotics administered as oral or intravaginal formulations. Patient counseling and education regarding treatment options, including adherence to prescribed treatments, appropriate hygienic practices, and treatment of symptomatic same-sex partners, are crucial to optimize patient outcomes and prevent recurrence.
TL;DR: The validity of the proposed definition of remission is supported by the persistence of remission in this study group, and its correspondence with patient satisfaction, and reduced disability.
Abstract: Objective: In the treatment of chronic diseases, remission is commonly used as a meaningful treatment goal, synonymous with the absence of significant clinical signs and symptoms of a disease, but not representing a cure. The objective of this paper is to propose a definition for remission for use as an outcome to evaluate the long-term efficacy of therapies for chronic pain. Methods: Data from a randomized clinical trial (NCT01609972) testing the efficacy of spinal cord stimulation in low back and leg pain subjects was used to evaluate the association between pain and functional outcomes and identify the cut-off value to predict remission. Available data over 24-month assessment period included visual analog score (VAS), disability (Oswestry Disability Index [ODI]), patient and clinician global impression of change (PGIC and CGIC), and patient satisfaction. Cluster analysis, Pearson's correlation coefficients, sensitivity, and specificity analyses were used to evaluate its utility in predicting higher patient functionality and satisfaction. Results: Though the term remission has been used in the chronic pain field, a consistent definition has not been previously established. Based on the analysis of the clinical data, we propose that a sustained (≥6 months) pain score of ≤3.0 cm out of 10 cm on VAS be defined as remission. Applying this definition to the clinical trial data: subjects in remission at 24 months versus non-remitters were significantly more likely to be in the highest functional category of minimally disabled according to the ODI (31.5 vs. 8.2%, respectively, p = 0.001), and be 'very satisfied' (75.7 vs 22.6%, respectively, p < 0.001). Conclusions: The validity of the proposed definition of remission is supported by the persistence of remission in this study group, and its correspondence with patient satisfaction, and reduced disability. Further evaluation of the definition using clinical data from other long-term studies is needed.
TL;DR: A systematic literature review of hyperglycemia in acute ischemic stroke patients addressed several questions: timing of glucose control, target range, type of insulin delivery, duration and practicability of glucose-lowering protocols.
Abstract: Hyperglycemia on hospital admission is a common phenomenon in acute ischemic stroke patients and represents an independent predictor of poor clinical outcome with or without acute recanalization therapies (systemic thrombolysis or mechanical thrombectomy). Effective restoration of normoglycemia is considered to be beneficial, but conclusive evidence from randomized controlled clinical trials and specific recommendations are lacking. In addition, aggressive glucose control can be complicated by hypoglycemia leading to early neurological deterioration. We conducted a systematic literature review with the aim of addressing several questions: timing of glucose control, target range, type of insulin delivery, duration and practicability of glucose-lowering protocols. Special issues regarding mechanical thrombectomy and glycemic variability can then be investigated in future trials which are also being considered.
TL;DR: Frontal and striatal GM atrophy may contribute to the emergence of VH in DLB, which may be fostered by the more severe attention deficits.
Abstract: Objectives: Visual hallucinations (VH) are common in Lewy body disease (LBD), and have been associated with cognitive and structural brain alterations. Evidence so far concerns mainly Parkinson's disease (PD), but little is known about symptom-specific pathophysiological mechanisms across the LBD spectrum, especially related to the presence of dementia. The aim of the present pilot study was to investigate the neuroanatomical, and neuropsychological characteristics related to VH in two forms of LBD, namely dementia with Lewy bodies (DLB) and PD without dementia. Methods: Whole brain voxel-based morphometry (VBM) analyses on 3D MRI acquired structural brain scans, and neuropsychological testing were performed on 28 clinically diagnosed DLB (11 with VH, 17 NVH), and 24 PD (9 with VH, and 15 NVH) patients. In order to assess differences in gray matter (GM) regional volumes, and cognitive performance, hallucinating patients for each group were compared with corresponding non-hallucinating ones. Results: DLB patients with VH presented significantly worse visual attention deficits compared to those without, which persisted even when controlling for visual perception. Whole brain VBM analysis revealed decreased GM volume in DLB with VH in the right superior and medial frontal gyri, putamen, caudate nucleus and insula. Subcortical regional volumes were also significantly associated with visual attention performance. Hallucinating PD patients, instead, presented more severe executive dysfunction, but VBM showed no volumetric differences between the two PD subgroups. Post hoc region of interest analyses revealed striatal GM loss in PD with VH. Conclusion: Frontal and striatal GM atrophy may contribute to the emergence of VH in DLB, which may be fostered by the more severe attention deficits. Striatal GM loss and executive dysfunction, instead, appeared to underlie VH in PD without dementia.
TL;DR: This article will discuss non-medical switching in the US, taking into account the different parties involved, such as patients, health care providers, pharmacists, payers, and pharmacy benefit managers, with the aim of providing a detailed overview of this complex and evolving topic.
Abstract: Non-medical switching of medication, whereby a patient's treatment regimen is changed for reasons other than efficacy, side effects, or adherence, is often related to drug formulary changes aimed at reducing drug costs. In the era of health care reform, while cost-cutting measures are important, there is considerable evidence that non-medical switching, particularly when applied to medication used to treat chronic conditions such as diabetes, may impact patient outcomes, medication-taking behavior, and use of health care services. Ultimately, overall costs may be increased, as savings by insurers are cancelled out by higher costs to the health care system as a whole, such as extra administration, treatment failure from new medicines, and increased adverse events. The emergence of biosimilar and follow-on biologic treatments raises further questions among patients receiving biologic treatments, with patient advocacy groups calling for clear legislation to ensure that patients with complex or chronic conditions continue to receive effective, evidence-based medications for their disease. This article will discuss non-medical switching in the US, taking into account the different parties involved, such as patients, health care providers, pharmacists, payers, and pharmacy benefit managers, with the aim of providing a detailed overview of this complex and evolving topic.
TL;DR: There is low awareness and underestimation of the disease burden amongst healthcare professionals; a high economic burden associated with the disease; relapse rates to treatment represent additional mortality and morbidity and further costs for the healthcare system; and better treatments are necessary to combat this public health threat.
Abstract: Toxoplasmosis, a disease with diverse clinical manifestations, caused by infection with the Apicomplexan parasite, Toxoplasma gondii (T. gondii), is a major source of morbidity and mortality in the United States. Although toxoplasmosis prevalence and mortality have declined over the past two decades, the CDC considers this disease a neglected parasitic infection requiring public health action. Here, we overview the literature to bring attention to the prevalence of the disease in the United States, and high economic burden associated with the disease. The conclusions to be drawn are clear: there is low awareness and underestimation of the disease burden amongst healthcare professionals; a high economic burden associated with the disease; relapse rates to treatment represent additional mortality and morbidity and further costs for the healthcare system; and better treatments are necessary to combat this public health threat.
TL;DR: Elevated neutrophil count and NLR may be relevant markers for severe GI involvement and nephritis, whereas platelet count and MPV were the only laboratory parameters associated with disease recurrence.
Abstract: Objectives: Henoch Schonlein Purpura (HSP) is the most common systemic vasculitis of childhood and often has a self-limiting course. We aimed to study whether practical laboratory parameters at the diagnosis predict disease course including recurrence and nephritis in addition to severe gastrointestinal involvement in children with HSP. Methods: This retrospective cohort study included 214 HSP patients, 43.5% (n = 93) female and 56.5% (n =121) male, who were diagnosed in our department. Laboratory parameters before treatment, including neutrophil, lymphocyte and platelet counts, mean platelet volume (MPV), neutrophil-to-lymphocyte (NLR), and platelet-to-lymphocyte ratios (PLR) were obtained retrospectively. Age at diagnosis, duration of follow-up, gender, preceding infections, medications, arthritis and arthralgia, abdominal pain, severe GI involvement, invagination, renal involvement and presence of nephritis, outcomes, and presence of recurrences were retrospectively recorded from medical files. Severe GI involvement was determined as severe colicky abdominal pain, bowel edema in ultrasonography or overt GI bleeding. A relapse was defined as a new flare of cutaneous lesions or other manifestations in a patient at least four asymptomatic weeks after the initial HSP episode. Results: Mean age at diagnosis was 7.6 ± 3.1 years. Biopsy-proven nephritis was found in 16 (7.5%) patients. Severe GI involvement was present in 77 (36%) patients, whereas only 12 (5.6%) patients were diagnosed with intussusception and in 29 (13.5%) patients, HSP recurred. Neutrophil count and NLR were found higher in HSP patients with severe gastrointestinal involvement and biopsy-proven nephritis. Additionally, only platelet count was lower and MPV was higher in patients with recurrent HSP. Conclusion: Elevated neutrophil count and NLR may be relevant markers for severe GI involvement and nephritis, whereas platelet count and MPV were the only laboratory parameters associated with disease recurrence.
TL;DR: The literature for the risk of postoperative bleeding with NSAIDs use, with a particular focus on ibuprofen, is assessed, suggesting that the consensus guideline recommendations for acetaminophen and against NSAID use in dengue treatment should be reconsidered in light of current evidence regarding the risks and benefits of each agent.
Abstract: Consensus guidelines for treatment of dengue fever from the World Health Organization and US Centers for Disease Control recommend acetaminophen to manage pain and fever but contraindicate nonstero...
TL;DR: A systemic review and meta-analysis of the relevant studies revealed that earlier age at menarche was significantly associated with insulin resistance.
Abstract: Objectives: We aimed to conduct a systemic review and meta-analysis of the relevant studies to further investigate the association between age at menarche and insulin resistance.Methods: PubMed, EM...
TL;DR: A review of the available literature on the epidemiology and clinical considerations of several clinical syndromes that involve a number of organs associated with Influenza infection and the effects of type of influenza, antiviral therapy, vaccination and other therapies on the outcome of these complications.
Abstract: Severe influenza infection represents a leading cause of global morbidity and mortality. Several clinical syndromes that involve a number of organs may be associated with Influenza infection. However, lower respiratory complications remain the most common and serious sequel of influenza infection. These include influenza pneumonia, superinfection with bacteria and fungi, exacerbation of underlying lung disease and ARDS. This review analyzes the available literature on the epidemiology and clinical considerations of these conditions. It also provides an overview of the effects of type of influenza, antiviral therapy, vaccination and other therapies on the outcome of these complications.
TL;DR: The results suggest the importance of simultaneous glycemic and lipids control in the prevention of hyperuricemia and implicate the value of TyG to optimize the risk stratification and prevention.
Abstract: Objectives: Hyperuricemia is a metabolic abnormality that has cast an enormous burden on global healthcare. Previous studies have revealed the close association between insulin resistance and hyper...
TL;DR: Compared with psychiatrists, non-psychiatrists exhibited less confidence in diagnosing adult ADHD and experienced greater difficulty determining optimal treatment regimens.
Abstract: Objective: This study examined adult attention-deficit/hyperactivity disorder (ADHD) screening and management patterns among healthcare provider (HCP) subgroups.Methods: An online survey of...
TL;DR: Combined therapy with SGLT-2i plus GLP-1RA potentially provides effective durable glycemic control and CV benefits due to their complementary actions on the defects of T2D.
Abstract: Type 2 diabetes (T2D) has a complex pathophysiology composed of multiple underlying defects that lead to impaired glucose homeostasis and the development of macrovascular and microvascular complica...
TL;DR: A review of the pathogenesis of cardiac involvement in patients with beta-thalassemia major, the advances in the management of these patients and the future prospects is looked at.
Abstract: Despite the advances in the management of thalassemia major, heart disease remains the leading cause of mortality in patients afflicted with this disorder. Cardiac involvement in thalassemia encompasses a spectrum of disorders including myocardial dysfunction, arrhythmias, pulmonary hypertension, and peripheral vascular disease. Although cardiac siderosis (accumulation of iron in cardiac myocytes) as a consequence of repeated blood transfusions is deemed to be the main etiologic factor for myocardial dysfunction in transfusion-dependent patients, the significance of other pathophysiologic mechanisms is being increasingly recognized especially in non-transfusion dependent patients. Management of cardiac complications in thalassemia major hinges on the treatment of the underlying pathophysiology, which often is unmitigated iron overload. The prevalence and predictors of cardiac complications in 'ex-thalassaemics' [thalassaemic patients undergoing allogeneic hematopoietic stem cell transplantation (HSCT) is unknown at present. In this review, we look at the pathogenesis of cardiac involvement in patients with beta-thalassemia major, the advances in the management of these patients and the future prospects.
TL;DR: In elderly patients with AECOPD, hypocalcemia may be related to the disease progression, respiratory infection rate, and hospital stay of patients with C-reactive protein level.
Abstract: Introduction: Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is an important disease of hospitalized elderly patients, who often have electrolyte imbalances. This study was performed to analyze total serum calcium levels in elderly patients with AECOPD and identify the correlation between hypocalcemia and AECOPD. Methods: 153 elderly patients with AECOPD served as the observation group, and 115 healthy elderly people undergoing physical examinations served as the control group. Differences in the corrected serum calcium, albumin (ALB), and neutrophil/lymphocyte ratio (NLR) were analyzed between the observation and control groups before and after treatment. The incidence of hypocalcemia was compared among patients at different ages and with different pulmonary function classifications before treatment. The relationship between hypocalcemia and respiratory infection was analyzed. Differences in the pretreatment NLR, ALB, logarithm of the serum C-reactive protein level (LogCRP), and hospital stay were compared between patients with and without hypocalcemia. Results: The corrected serum calcium level (P < 0.001), NLR (P = 0.001) and albumin level (P < 0.001) were significantly different among the pretreatment group, post-treatment group, and control group. The serum calcium level, LogCRP, and NLR were significantly lower after than before treatment (P < 0.05). Significant differences in the incidence of hypocalcemia were found among patients of different ages (P = 0.002). The respiratory infection rate (P < 0.001), hospital stay (P < 0.001), NLR (P = 0.007), and LogCRP (P < 0.001) was higher in patients with than without hypocalcemia. However, the albumin level was lower in patients with than without hypocalcemia (P < 0.001). Conclusions: In elderly patients with AECOPD, hypocalcemia may be related to the disease progression, respiratory infection rate, and hospital stay of patients with AECOPD.
TL;DR: The prognostic value of poor OS and PFS of TP53 commutation in EGFR mutant lung cancers is confirmed, and it should be further investigated and validated regarding the prognostic role of TP 53 mutation subtypes.
Abstract: Background The prognostic value of TP53 commutation in epidermal growth factor receptor (EGFR) mutant lung cancer is controversial and we therefore conducted this systematic review and meta-analysis. Methods A systematic search was carried out in Pubmed, Web of Science, the Cochrane Library, Medline and Embase up to 19 April 2018. The pooled hazard ratio (HR) of overall survival (OS) and progression-free survival (PFS), the relative risk (RR) of objective response rate (ORR) were calculated. Results Overall, a total of eight studies comprising 2979 patients were included. When generally comparing TP53 mutation group with TP53 wild-type group, we confirmed the prognostic value of poor OS of TP53 in EGFR mutant lung cancers (HR 1.73, 95% CI 1.22-2.44, P = 0.002). In subgroup analysis of OS, the prognostic value was maintained in patients treated with EGFR tyrosine kinase inhibitors (TKIs) but not in those treated with non-targeted therapy (HR 2.29, 95% CI 1.39-3.76, P = 0.001), and was also maintained in patients with advanced-stage lung cancers rather than those of all stages (HR 2.00, 95% CI 1.11-3.61, P = 0.021). For patients treated with EGFR TKIs, TP53 commutation was predictive of a poor PFS (HR 2.18, 95% CI 1.42-3.36, P < 0.001) but the prognostic value on ORR was not observed (RR 1.15, 95% CI 0.92-1.44, P = 0.212). Additional subgroup analysis based on TP53 mutation subtypes was not pooled due to limited data. Conclusion Generally we confirmed the prognostic value of poor OS and PFS of TP53 commutation in EGFR mutant lung cancers, and it should be further investigated and validated regarding the prognostic role of TP53 mutation subtypes.
TL;DR: It is demonstrated that text message intervention indeed leads to a decline in HbA1c and improvement of blood glucose control and no convincing evidence was found on quality of life improvement, satisfaction, body mass index (BMI), blood lipid levels, the frequency of hypoglycemia, self-monitoring ofBlood glucose or complications reduction.
Abstract: Background: Compared with traditional outpatient follow up, short message service (SMS) provides more convenience for diabetes self-management. However, the feasibility, effectiveness, and satisfaction of SMS intervention remain unclear.Methods: A systematic retrieval of databases, including PubMed, EMBASE, and Cochrane Library, was used to evaluate the effect of SMS on the diabetes glycemic control. Complete quantitative reports on the changes of glycosylated hemoglobin (HbA1c) before and after intervention were collected. The study type was limited to randomized controlled trials (RCTs).Results: 13 RCTs were identified as eligible for this subject. Overall result revealed a statistical decline of HbA1c by -0.62% (95% CI -0.82 to -0.41). The longest intervention duration was 12 months with the noteworthy improvement of HbA1c by -1.63% (-2.27 to -0.99). Compared with control groups, five trials quantitatively demonstrated a significant decline in fasting plasma glucose (FPG) by -0.45 (95% CI -0.7 to -0.19) and -1.05 (95% CI -1.35 to -0.75) in 2-h postprandial blood glucose (2hPBG).Conclusions: This meta-analysis demonstrated that text message intervention indeed leads to a decline in HbA1c and improvement of blood glucose control. No convincing evidence was found on quality of life improvement, satisfaction, body mass index (BMI), blood lipid levels, the frequency of hypoglycemia, self-monitoring of blood glucose or complications reduction.
TL;DR: This perspective highlights promising late-stage drug candidates in the treatment of toxoplasmosis, including the calcium-dependent protein kinase 1 (CDPK1) which plays an essential role in the intracellular replicative cycle of the parasite, and has no direct mammalian homolog.
Abstract: No new drugs for treatment of toxoplasmosis have been approved in over 60 years, despite the burden of toxoplasmosis on human society. The small selection of effective drugs is limited by important...
TL;DR: MEFV variants in exon 10 may affect clinical presentation of HSP in populations where FMF is common, and physicians should be aware of FMF possibility in children with intussusception and lower hemoglobin, higher serum IgA, leukocyte, and platelet count.
Abstract: Objectives: Henoch-Schonlein purpura (HSP) is characterized by non-thrombocytopenic palpable purpura, abdominal pain, and arthralgia/arthritis. We aimed to describe the clinical presentations of ch...